Provider Demographics
NPI:1992272405
Name:BOGACZ, SAMANTHA NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:BOGACZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 CONNECTICUT ST STE A
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7015
Mailing Address - Country:US
Mailing Address - Phone:192-863-9072
Mailing Address - Fax:219-793-1244
Practice Address - Street 1:3000 MURVIHILL RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5960
Practice Address - Country:US
Practice Address - Phone:219-286-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28247405A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily